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111111111111111 Form Aooroved. OMB No. 2050-0039 rrensc yi Y N.,. UNIFORM HAZARDOUS 1. Generator ID Number 2. Page 1 of 3. Emergency Response Phone 4. Manifest Tracking Number 18775772669 013 5 FLE WASTE MANIFEST CAL000373074 i 5. Generator's Name and Mailing Address Generator's Site Address (if different than mailing address) Dollar General #13632 Dollar General#13632 2098008944 2907 E. WATERLOO ROAD 2907 E. WATERLOO ROAD Generator's Phone: STOCKTON, CA 95205-2926 STOCKTON CA 95205-2926 6. Transporter 1 Company Name U.S. EPA ID Number Stericycle Specialty Waste Solutions Inc IMNS01211011092.4 7. Transporter 2 Company Name U.S. EPA ID Number 8. Designated Facility Name and Site Address General Environmental Mgt, LLC U.S. EPA ID Number 11855 White Rock Road Rancho Cordova, CA 95742 Facility's Phone 9a 9b. U.S. DOT Description (including Proper Shipping Name, Hazard Class, ID Number, 10. Containers 11. Total 12. Unit 13. Waste Codes HM and Packing Group (if any)) No. Type Quantity Wt.Nol. o X 6N1950, Waste Aerosols, flammable 2.1, ERG#126 1 CF 00004 P 331 D001 z 2. w c� 3. 4. 14. Special Handling Instructions and Additional Information 1.110541(Aerosols) 15. GENERATOR'S/OFFEROR'S CERTIFICATION: I hereby declare that the contents of this consignment are fully and accurately described above by the proper shipping name, and are classified, packaged, marked and labeled/placarded, and are in all respects in proper condition for transport according to applicable intemationaland national governmental regulations. If export shipment and I am the Primary Exporter, I certify that the contents of this consignment conform to the terms of the attached EPA Acknowledgment of Consent. I certify that the waste minimization statement identified in 40 CFR 262.27(a) (if I am a large quantity generator) or (b) (if] am a small quantity generator) is true. Generator's/Offerors Printedr;r ed Name Signature �A4ea4Ir --Day Year ��It 20 61011 F- 16. International Shipments Import to U.S. El Export f6U_.S. Port of entry/exit: ? Transporter signature (for exports only): Date leaving U.S.: W 17. Transporter Acknowledgment of Receipt of Materials Transporter 1 Printed/Typed Name Signature Month Day Year a Jared Marciei zTransporter 2 Printed(ryped Name nature Month Day Year - 18. Discrepancy 18a. Discrepancy Indication Space ❑ Quantity, ❑ Type ❑ Residue ❑ Partial Rejection ❑ Full Rejection Manifest Reference Number: 18b. Alternate Facility (or Generator) U.S. EPA ID Number J_ V LL Facility's Phone: w 18c. Signature of Alternate Facility (or Generator) Month Day Year Q Z H19. Hazardous Waste Report Management Method Codes (i.e., codes for hazardous waste treatment, disposal, and recycling systems) G 1 2. 3. 4. 20. Designated Facility Owner or Operator: Certification of receipt of hazardous materials covered by the manifest except as noted in Item 18 Prtn�dffyped Name 9th pa�� Ye WAFGM 8700-22 (Rev. 12-17) Previous edl6ons are obsolete. n . ,N,Tcn FOCI, 1 Tf1 Fpe'c a.MAkII S i YS'��